Nokea
Four days after admission for cirrhosis of the liver, the nurse observes the following when assessing a male client: increased irritability, asterixis, and changes in his speech pattern. Which of the following foods would be appropriate for his bedtime snack?
- A. Fresh fruit
- B. A milkshake
- C. Saltine crackers and peanut butter
- D. A ham and cheese sandwich
Correct Answer: B
Rationale: While fresh fruit is low in protein, a milkshake is a better choice as it provides carbohydrates and some protein in a form that is easier to digest, which is crucial for clients with cirrhosis to avoid ammonia buildup. A milkshake is appropriate as it provides carbohydrates, which are needed to prevent protein catabolism, and has lower protein content compared to options like peanut butter or ham, reducing the risk of ammonia accumulation. (C, D) Both saltine crackers with peanut butter and a ham and cheese sandwich are high in protein, which can increase ammonia levels, exacerbating hepatic encephalopathy.
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Proper positioning for the child who is in Bryant's traction is:
- A. Both hips flexed at a 90-degree angle with the knees extended and the buttocks elevated off the bed
- B. Both legs extended, and the hips are not flexed
- C. The affected leg extended with slight hip flexion
- D. Both hips and knees maintained at a 90-degree flexion angle, and the back flat on the bed
Correct Answer: A
Rationale: The child's weight supplies the countertraction for Bryant's traction; the buttocks are slightly elevated off the bed, and the hips are flexed at a 90-degree angle. Both legs are suspended by skin traction. The child in Buck's extension traction maintains the legs extended and parallel to the bed. The child in Russell traction maintains hip flexion of the affected leg at the prescribed angle with the leg extended. The child in '90-90' traction maintains both hips and knees at a 90-degree flexion angle and the back is flat on the bed.
The nurse is observing the ambulation of a client recently fitted for crutches. Which observation requires nursing intervention?
- A. Two finger widths are noted between the axilla and the top of the crutch.
- B. The client bears weight on his hands when ambulating.
- C. The crutches and the client's feet move alternately.
- D. The client bears weight on his axilla when standing.
Correct Answer: D
Rationale: Bearing weight on the axilla can cause nerve damage (e.g., brachial plexus injury); crutches should support weight on the hands.
A 40-year-old client is admitted to the hospital for tests to diagnose cancer. Since his admission, he has become dependent and demanding to the nursing staff. The nurse identifies this behavior as which defense mechanism?
- A. Denial
- B. Displacement
- C. Regression
- D. Projection
Correct Answer: C
Rationale: Regression involves reverting to an earlier developmental stage, such as dependency, in response to stress like a cancer diagnosis.
Several months after antibiotic therapy, a child is readmitted to the hospital with an exacerbation of osteomyelitis, which is now in the chronic stage. The mother appears anxious and asks what she could have done to prevent the exacerbation. The nurse's response is based on the knowledge that chronic osteomyelitis:
- A. Is caused by poor physical conditions or poor nutrition
- B. Often results from unhygienic conditions or an unclean environment
- C. Is directly related to sluggish circulation in the affected limb
- D. May develop from sinuses in the involved bone that retain infectious material
Correct Answer: D
Rationale: Areas of sequestrum may be surrounded by dense bone, become honeycombed with sinuses, and retain infectious organisms for a long time, leading to chronic osteomyelitis exacerbation.
A client is admitted with sickle cell crises and sequestration. Upon assessing the client, the nurse would expect to find:
- A. Decreased blood pressure
- B. Moist mucus membranes
- C. Decreased respirations
- D. Increased blood pressure
Correct Answer: A
Rationale: Sickle cell crisis with sequestration can lead to hypovolemia due to blood pooling in organs, resulting in decreased blood pressure.